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c*'may County <br /> r J" Safety and Buildings Division <br /> rk=` D s 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> SPs {� Madison,W1 53707-7162 J 8'0,7?0 <br /> . 1 jl A <br /> Sanitary Permit Application State Trat>SJa'c`tionN/umber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit Gown, y e04 kil <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. /�/ <br /> 1. Application Information—Please Print All Information 10Z,711 k Q <br /> Property Owner's Name / Parcel# <br /> &na!� NL�i,e/ z' I 0/-aw-oaaz <br /> Property Owner's Mailing Address /) Property Location <br /> Z44" Govt.Lot <br /> Ci[ tate Zip Code Phone Number3 Z. <br /> �y fie, Section( 'le tCIC Ong') <br /> 11.Ty0o of Building(check all that apply) Lw# T N; R E oiW/ <br /> ❑1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name C7' <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> �Town of_ 06 s1Vte <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System ❑Replacement System y p y ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B• ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rmelgpdsf) Dispersal Area Required(st) Dispersal Area Proposed Is System Elevation <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanksy o 0 2 a t; m m <br /> o_U rn q m is_U a <br /> Septic or Holding Tank !Z�—t! Z <br /> Dosing Chamber 75' <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plrlomot7iswti�e_�— <br /> s Name Plum Signature MPrMPRS Numbcr Business Phone Number <br /> 8S7gS 7i5'56G-o2aZ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 27ZOO SBP <br /> VIII.Countyffiepartment Use Only <br /> Approved ❑Disapproved Permit Fee 0 D I Date issued Issuing Agent Signa re <br /> ❑Owner Given Reason for Denial 1 ' 37-T- <br /> IX.Conditions of ApprovalfReasons for Disapproval <br /> nnEcEivEr,---, <br /> Attach to complete plays for the system and submit to the County only on paper not less than a 12 z I la slze <br /> nUU <br /> JUL 282016 <br /> SBD-6398(R.I[/11) BURNETT COUNTY <br /> ZONING <br />